Transcript JCI-Dark PP Presentation

Karen H. Timmons
President and Chief Executive Officer
Joint Commission International
Association of Companies Health Insurance Funds
13 March 2009
Prague, Czech Republic
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Joint Commission International:
An Overview
– To improve the safety and quality
of care in the international
community through the provision of
education, publications,
consultation, evaluation, and
accreditation services
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Mission of
Joint Commission International
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“So I am called eccentric for saying in
public that hospitals, if they want to be
sure of improvement,
– Must find out what their results are.
– Must analyze their results, to find their
strong and weak points.
– Must compare their results with those of
other hospitals.
– Must welcome publicity not only for their
successes, but for their errors.”[1]
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Ernest A. Codman:
End Result Theory
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“Encourage those which are
doing the best work, and to
stimulate those of inferior
standard to do better.”
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The American College of Surgeons
described the need for
standardization of hospitals through
accreditation as the need to:
The Joint Commission
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– An independent, non-profit, nongovernmental agency
– Accredits over 15,000 health care
organizations in the United States
The Joint Commission standards:
– Are filled with U.S. and state laws and regulations
– Include many “political” considerations such as
requirements for an organized medical staff
– Use American jargon such as “advanced directives”
– Rely on National Fire Protection Association
requirements for facility review–no international version
of these requirements
– Have a U.S. cultural overlay for patient rights
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Why International Standards?
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Brazil
Czech Republic
Germany
Italy
Poland
Portugal
P.R. of China
Republic of South Africa
Saudi Arabia
U.S.A.
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Standards Subcommittee:
How We Get Stakeholder Input
–Arabic
–Brazilian Portuguese
–Chinese
–Czech
–Danish
–European
Portuguese
–German
–Greek/Cyprus
–Italian
–Korean
–Japanese
–Spanish
–Turkish
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JCI Hospital Standards
Translations
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International Board of Directors
International Accreditation Committee
International Standards Committee
Regional Advisory Councils
Four International Offices
International translations of many products
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International Structure
Offices
– Headquarters
– Oak Brook, IL, USA
– Europe
– Ferney-Voltaire, France (edge of Geneva)
– Milan, Italy (Project Office)
– Middle East
– Dubai Health Care City
– Asia Pacific
– Singapore
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– International
– Asia-Pacific
– Europe
– Middle East
– Provide advice and counsel to JCI
management about standards and patient
safety initiatives
– Guidance on regional or cultural
adaptations
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Regional Advisory Councils
– BQS
– Danish Institute for Patient Safety
– Danish Institute for Quality and
Accreditation in Healthcare
(IKAS)
– European Parliament
– European Society for Quality in
Healthcare (ESQH)
– Fundación Acreditación
Desarrollo Asistencial
– Georgian Alliance for Patient
Safety
– Haute Autorité de Santé (HAS)
– Health Care Quality Indicator
Project
– HOPE (European Hospital
Federation)
– International Hospital Federation
– International Pharmaceutical
Federation (FIP)
– The Karolinska Institute
– Ministry of Health, State of Israel
– Ministry of Health, Turkey
– National Patient Safety Agency
– Socialstyrelsen
– Swedish Medical Injury Insurance
– WHO
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European Regional Advisory
Council
– Global knowledge disseminator of quality
improvement and patient safety
– Non-profit affiliate of the Joint Commission
– 236 accredited organizations in 35 countries
– Commitment to partnering with NGOs, HCOs,
etc.
– ISQua-accredited
– WHO Collaborating Centre for Patient Safety
Solutions
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JCI Today
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International Accreditation
Programs
Accredited Hospitals in Czech
Republic
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• Central Military Hospital
• Institute of Hematology and Blood
Transfusion
• Na Homolce Hospital
• A government or non-government
agency grants recognition to health
care institutions which meet certain
standards that require continuous
improvement in structures, processes,
and outcomes
• Usually a voluntary process
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Accreditation – A Definition
– The U.S., Canada, and Australia have the oldest
accreditation systems
– In Europe, Germany, France, Ireland, and Spain have
new accreditation systems
– In Asia, China, Thailand, and Malaysia are
developing national accreditation programs
– The WHO, World Bank, and development banks
recognize and endorse the accreditation model
– The International Society for Quality in Health Care
(ISQua) accredits accrediting bodies
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Accreditation: A World Trend
Common Core of Health Care
Accreditation Around the World
 Administered by a recognized body
• Establishes and publishes standards
• Conducts objective on-site evaluations
• Publishes accreditation decision
• Consensus on standards of quality and safety
• Professionals serve as the external evaluators
 Focus is on continuous improvement
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 Professional involvement
• Maximize quality/minimize safety risk
• Improve patient care processes and outcomes
• Enhance patient safety
• Strengthen the confidence of patients,
professionals, and payors about the organization
• Improve the management of health services
• Enhance staff recruitment, retention, and
satisfaction
• Provide education on better/best practices
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What is Accreditation
Intended to Accomplish?
Increasing Requests for Ensuring
Quality and Safety for Medical Travel
• International Medical Travel Association issued position paper
advocating that international health care organizations be held
to high standards set by recognized accreditation authorities1
• American Medical Association adopted guiding principles on
medical tourism2
• Increasing exposure in international trade journals highlighting
the need to research quality when considering medical travel3
• Deloitte study mentions JCI in particular in reference to patients’
increasing concerns about quality in international hospitals4
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– Outline steps for care abroad for consideration by patients,
employers, insurers, and third parties
– Require patients to be made aware of their legal rights and have
access to physician licensing and facility accreditation
Accreditation
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– Assesses the capability of an
organization to provide good results
International Accreditation Philosophy
– Maximum achievable standards
– Patient-centered
– Culturally adaptable
– Process stimulates continuous improvement
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Joint Commission International
Accreditation
The Accreditor’s Tools
Standards
Evaluation Methodology
Patient Safety Goals and Tools
Data on Performance and Benchmarks
Education
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– A system framework
– Address all the important managerial and
clinical functions of a health care organization
– Focus on patients in context of their family
– A balance of structure, process, and
outcomes standards
– Set optimal, achievable expectations
– Set measurable expectations
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Standards
– The heart of any accreditation program is the
standards upon which all else is based – the
evaluation methodology, decision process,
evaluator training, and other operational
elements
– Thus, a standard must be “good”, not just on
the day the standard is written, but on a
continuing basis
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Standards are Continually a
“Work in Progress”
– Standards have multiple dimensions and thus have
multiple sources of evidence
– Policy – document review
– Knowledge – staff training logs, interviews with
staff
– Practice – clinical observation, patient interviews
– Documentation of practice – open and closed
record review
– A good standard permits a convergent validity scoring
process – all surveyors evaluating all types of
evidence and reaching one score
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Evidence of Performance is
Available
Joint Commission International
Standards
– Patient-Centered Standards
– Access to Care and Continuity of Care
– Patient and Family Rights
– Assessment of Patients
– Care of Patients
– Anesthesia and Surgical Care
– Medication Management and Use
– Patient and Family Education
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– Organized Around Important Functions
JCI Standards, continued
– Organization Management Standards
– Quality Improvement and Patient Safety
– Prevention and Control of Infections
– Governance, Leadership, and Direction
– Facility Management and Safety
– Staff Qualifications and Education
– Management of Communication and
Information
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– Organized Around Important Functions
– Set of components that work together toward
common goal
– Evaluation of how - and how well - the
organization’s systems function
– Addresses interrelationships of elements
– Translates standards compliance issues into
potential vulnerabilities as far as patient
quality and safety
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Patient Tracer: Systems Analysis
– Represent proactive strategies to reduce risk of
medical error and reflect good practices
proposed by leading patient safety experts
– Incorporating these new tools into our
accreditation requirements is a significant step
– Organizations taking responsibility for using the
IPSG to foster an atmosphere of continuous
improvement is even more important
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International Patient Safety Goals
and Tools
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Identify patients correctly
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Improve effective communication
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Improve the safety of high-alert medications
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Ensure right-site, right-patient, right-procedure
surgery
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Reduce the risk of health care-associated
infections
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Reduce the risk of patient harm from falls
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JCI International Patient Safety Goals
JCI’s Measurement Strategy
Accreditation is continuous
Accreditation status publicly disclosed
Complements existing standards requirements
International comparisons
Meets needs of multiple stakeholders
Develop and identify measures that address clinical
and managerial dimensions
– Need for and rigor of data validation
– Measurement system supported by IT platform
– JCI currently has 20 performance measurement
requirements
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• Pilot program addressing international clinical cardiac
indicators
• Enables hospitals to evaluate the current status of
their coronary artery bypass graft (CABG) and valverelated surgery risk-adjusted mortality rates
• Encourages hospitals to implement and measure
rates of improvement using the New York State
Department of Health (NYSDOH) Cardiac Surgery
Reporting System (CSRS) as a model
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International Cardiac Surgery
Benchmarking (ICSB) Project
• Participating hospitals will get information to help
them improve quality of care and assess a patient’s
risk factors before cardiac surgery
• Multi-site and multi-country use of the ICSB
assessment and reporting tool to guide organized
quality improvement and benchmarking efforts
• Long-term goal–to improve the outcomes of cardiac
surgical procedures in participating organizations
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ICSB Project Objectives
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Help Prevent Errors in Your Care
Help Avoid Mistakes in Your Surgery
Information for Living Organ Donors
Five Things You Can Do to Prevent Infection
Help Avoid Mistakes With Your Medicines
What You Should Know About Research Studies
Planning Your Follow-up Care
Help Prevent Medical Test Mistakes
Know Your Rights
Understanding Your Doctors and Other Caregivers
What You Should Know About Pain Management
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Speak Up™
– Sentinel Event database collects data from
accredited organizations on errors that have occurred
– Information in database led to the publication of
Sentinel Event Alert, published by The Joint
Commission
– Sentinel Event Alerts highlight significant risk areas in
care
– Offer suggestions and recommendations for
mitigating risk
– Latest Alert focuses on information technology
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Sentinel Event Database
Sentinel Event Experience to Date
741
698
631
492
442
341
218
212
189
175
132
113
86
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992
Events of wrong site surgery
Inpatient suicides
Operative/post op complications
Events relating to medication errors
Deaths related to delay in treatment
Patient falls
Assault/rape/homicide
Retained foreign objects
Deaths of patients in restraints
Perinatal death/injury
Transfusion-related events
Infection-related events
Deaths following elopement
Anesthesia-related events
Fires
“Other”
= 5632 RCAs
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Client name/ Presentation Name/ 12pt - 38
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Of 5632 sentinel events reviewed by the Joint Commission,
January 1995 through December 2008:
– That an organization is
doing the right things and
doing them well;
– Thereby significantly
reducing the risk of harm in
the delivery of care; and
– Optimizing the likelihood of
good outcomes.
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Accreditation Represents a Risk
Reduction Strategy
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The Value and Impact of
Accreditation
– What is the evidence that
– Accreditation improves quality and safety
of care?
– High quality lowers cost of health care?
– The cost of implementing accreditation
standards is worth the achievable
benefit?
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Impact of Accreditation
– The process of Joint Commission
International accreditation has set many of
the fundamental principles that guide health
care organizations today
– Many of these principles are routine in health
care today but were revolutionary in their time
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Impact of Accreditation (cont’d)
Medical Records
• First required in 1917, many considered
the medical record unnecessary
• Today the medical record is inarguably
the central point of information gathering
for treatment decisions, research, patient
monitoring, outcomes measurement, and
even billing
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Impact of Accreditation:
Some Examples
Infection Control Programs
– In the mid-1950s, patients, especially surgery
patients and newborns, acquired infections in
epidemic proportions
– In the 1950s, hospitals were required to appoint
infection control committees to direct activities
aimed at curbing epidemics of infections
– Infection control programs were created that
reduced the spread of devastating infectious
agents
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Impact of Accreditation:
Some Examples
Impact of Accreditation:
Some Examples
Fire Safety
– Non-smoking standards for hospitals were developed due to the
adverse effects of passive non-smokers and significant fire
hazards
– Protects patients from a life or death they would not have wished
– Requires organizations to establish Do-Not-Resuscitate (DNR)
standards and request an advance directive from each patient so
the individual’s wishes can be documented in the patient chart
– In the 1980s only 20% of hospitals addressed this issue; since the
implementation of the standard, nearly 100% of accredited
organizations are in compliance with the standard
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Advance Directives
– JCI has conducted descriptive research with a sample
of accredited hospitals to determine the value of
accreditation
– Accredited hospitals report significant improvements in:
– Leadership
– Medical records management
– Infection control
– Reduction in medication errors
– Staff training and professional credentialing
– Improved quality monitoring
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Accreditation: The Value Equation
– Longo study showed that accreditation is a significant
factor in whether facilities engaged in actions widely
recognized to improve patient safety; advocates
accreditation as a means for improving health care5
– Health Affairs report indicated that Joint Commission
accreditation requirements influenced hospitals’
efforts toward implementing patient safety initiatives6
– Study in Hospital Topics found accreditation to be
effective in driving efforts to reduce errors7
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Recent Studies Support the Value of
Joint Commission Accreditation
to address the problem of
patient safety worldwide
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WHO
World Alliance
for Patient
Safety
World Alliance for Patient Safety:
Ten Action Areas
Solutions to improve
patient safety
Global Patient Safety Challenges :
1. Clean Care is Safer Care
2. Safe Surgery Saves Lives
High 5s
Patients for
Patient Safety
International
Classification for
Patient Safety (ICPS)
Reporting & Learning
Technology for Patient
Safety
Knowledge Management
Special projects:
- Education
- Radiotherapy
- Rewarding excellence
- When things go wrong
- Vincristine sulphate
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Research for
Patient Safety
Catalyse
countries’ action
to achieve
safety of care
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Solutions for Patient Safety
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Clean Care is Safer Care
• A patient engagement initiative
• Focus on individuals (“champions”), not
organizations
• Links to other World Alliance strands
• Creation of regional groups
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Patients for Patient Safety
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Taxonomy for Patient Safety
International Patient Safety Events
Taxonomy
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• Cornerstone of patient safety
communications
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Reporting and Learning
Research for Patient Safety
Canadian Adverse
Event Study
2004
Harvard Practice
Medical Study
1984
Danish Adverse
Event Study
2001
The Commonwealth
Fund Survey
2005
French Adverse
Event Study
2004
Australian Quality
in Healthcare
Study 1992
Adverse Events in
New Zealand
Study 2002
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Utah Colorado
Study 1992
Adverse events in
British Hospitals
1999-2001
– “To identify and clarify the role and
objectives of technology in improving
patient safety both in the developed and
developing world, and future directions
(research, education, implementation)
for the alliance regarding technology for
patient safety.”
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Technology for Patient Safety
– To achieve significant, sustained, and
measurable reduction in the occurrence of
patient safety problems over 5 years in at
least 7 countries and build an international,
collaborative learning community that
fosters the sharing of knowledge and
experience in implementing innovative
standardized operating protocols and
evaluating their impact.
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High 5s Project Objective
– Managing Concentrated Injectable Medicines
(U.K.)
– Assuring Medication Accuracy at Transitions in
Care (Canada)
– Performance of Correct Procedure at Correct
Body Sites (U.S.)
– Improved Hand Hygiene to Prevent Health CareAssociated Infections (New Zealand) (deferred)
– Communication During Patient Care Handovers
(Australia) (deferred)
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High 5s Standardized Operating
Protocols
– Identify Current Regional Safety Problems and
Solutions Available
– Understand Regional Barriers to Solutions
– Assess Risk of Solutions
– Adapt Solutions to Local/Regional Needs
– Develop/Disseminate Solutions
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WHO Collaborating Centre
for Patient Safety Solutions
Definition
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A Patient Safety Solution is any
system design or intervention that has
demonstrated the ability to prevent or
mitigate patient harm stemming from
the processes of health care.
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Sentinel Event Topic Areas
Expert Panels
National Agencies and Governments
Professional societies and organizations
Patient and family advocacy organizations
Field reviews
Open solicitations
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Topic Selection Process
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Confusing drug names is one of the most common causes of
medication errors and is a worldwide concern. With tens of
thousands of drugs currently on the market, the potential for error
created by confusing brand or generic drug names and
packaging is significant. The recommendations focus on using
protocols to reduce risks and ensuring prescription legibility or the
use of preprinted orders or electronic prescribing.
© Copyright, Joint Commission International
The widespread and continuing failures to correctly identify patients
often leads to medication, transfusion and testing errors; wrong person
procedures; and the discharge of infants to the wrong families. The
recommendations place emphasis on methods for verifying patient
identity, including patient involvement in this process; standardization of
identification methods across hospitals in a health care system; and
patient participation in this confirmation; and use of protocols for
distinguishing the identity of patients with the same name.
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Gaps in hand-over (or hand-off) communication between patient care
units, and between and among care teams, can cause serious
breakdowns in the continuity of care, inappropriate treatment, and
potential harm for the patient. The recommendations for improving patient
hand-overs include using protocols for communicating critical information;
providing opportunities for practitioners to ask and resolve questions
during the hand-over; and involving patients and families in the hand-over
process.
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Considered totally preventable, cases of wrong procedure or wrong site
surgery are largely the result of miscommunication and unavailable, or
incorrect, information. A major contributing factor to these types of errors
is the lack of a standardized preoperative process. The
recommendations to prevent these types of errors rely on the conduct of
a preoperative verification process; marking of the operative site by the
practitioner who will do the procedure; and having the team involved in
the procedure take a “time out” immediately before starting the
procedure to confirm patient identity, procedure, and operative site. 66
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While all drugs, biologics, vaccines and contrast media have a
defined risk profile, concentrated electrolyte solutions that are used
for injection are especially dangerous. The recommendations
address standardization of the dosing, units of measure and
terminology; and prevention of mix-ups of specific concentrated
electrolyte solutions.
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Medication errors occur most commonly at transitions. Medication
reconciliation is a process designed to prevent medication errors at patient
transition points. The recommendations address creation of the most
complete and accurate list of all medications the patient is currently taking—
also called the “home” medication list; comparison of the list against the
admission, transfer and/or discharge orders when writing medication orders;
and communication of the list to the next provider of care whenever the
patient is transferred or discharged.
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The design of tubing, catheters, and syringes currently in use is
such that it is possible to inadvertently cause patient harm through
connecting the wrong syringes and tubing and then delivering
medication or fluids through an unintended wrong route. The
recommendations address the need for meticulous attention to
detail when administering medications and feedings (i.e., the right
route of administration), and when connecting devices to patients
(i.e., using the right connection/tubing).
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One of the biggest global concerns is the spread of Human
Immunodeficiency Virus (HIV), the Hepatitis B Virus (HBV), and the
Hepatitis C Virus (HCV) because of the reuse of injection
needles. The recommendations address the need for prohibitions on
the reuse of needles at health care facilities; periodic training of
practitioners and other health care workers regarding infection control
principles; education of patients and families regarding transmission of
blood borne pathogens; and safe needle disposal practices.
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One of the biggest global concerns is the spread of Human
Immunodeficiency Virus (HIV), the Hepatitis B Virus (HBV), and the
Hepatitis C Virus (HCV) because of the reuse of injection
needles. The recommendations address the need for prohibitions on
the reuse of needles at health care facilities; periodic training of
practitioners and other health care workers regarding infection control
principles; education of patients and families regarding transmission of
blood borne pathogens; and safe needle disposal practices.
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Preventing Central Line Infections
Communicating Critical Test Results
Recognizing and Responding to
Deteriorating Patients
Preventing Pressure Ulcers
Preventing Harm from Patient Falls
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Next Set of Solutions
Next Set of Solutions (cont’d)
Prototype will target four audiences:
1. Government policy at ministry of health level
2. Health care organization at the CEO level
3. Clinician/provider levels
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4. Patient and family level